ICF provides domains of functioning as body functions, personal activities and societal participation to classifiy what a person can do in a certain environment. It provides a common language for communication and meaningful exchange of data. DSM5 has changed the requirements for describing the clinical significance of a DSM category. Now there it is required that "impairment" criteria is specified in accordance with the ICF ( International Classification of Functioning Disability and Health ) and operationally measured with the WHODAS 2.0;

1. Dr. T. Bedirhan Üstün
World Health Organization
Classifications, Terminologies, Standards
What is “Health Information”?
What is “Health” ?
What is “Health Information System” ?

2. a state
of complete
physical,
mental,
and social well-being
and not merely the
absence of disease or infirmity
Source: WHO’s Constitution, 1948
Health is…

3. History of Health
in the World
• 243 BC: plague in China
• 800 s : smallpox in Japan
• 1090s: dysentery in Palestine
• 1340s: "Black Death" in Europe
• 1830s: cholera worldwide
• 1917–19: influenza worldwide
• 1996- 2015 SARS, H1N1, Ebola …
http://www.mla-hhss.org/histlink.htm

4. Health Indicators
• Maternal Mortality
• Neonatal Mortality
• Infant Mortality
• Child Mortality
• Adult Mortality
• A g e -specific Mortality
• Cause-specific Mortality
• Stillbirth rate
• Risk factors…
http://www.who.int/gho/publications/world_health_statistics

5. Death - Life
CLASSIFICATIONS ,TERMINOLOGIES, STANDARDS … BUILDING BLOCKS OF HEALTH INFORMATION …

6. Between BIRTH a n d DEATH
© NewYorker – Jack Ziegler (2000)

7. “Definition” of an Elephant
• A pillar
• A huge fan
• A rope
• A huge mass
• A pointed hard horn
• A bad smell
• …

8. “Health” as a C o n t i n u u m
in M u l t i p l e Dimensions
10/20
2/20
1/20
Mild-Moderate vision impairment:
Needs eye glasses, contact lenses…
Severe vision impairment:
Needs operation
Complete vision impairment (blind):
Needs assistance –
pension, device, assistant
environmental modifications
Seeing Functions

9. A vector model
combination of multiple vectors of functioning
Vision
Hearing
Mobility
Social Activities
Work
Cognition
Selfcare

10. Mobility Spectrum
M u l t i p l e S U B Dimensions
• Sitting
• Crawling
• Getting out of the bed
• Bending body parts
• Standing
• Walking
– long distance
– inside the house/residence
• Running
– long distance
• Climbing
• Lifting objects
• Using tools - vehicles
– Assistive devices

11. Health C o n t i n u u m
can be used for interventions
Vision
0
10
20
30
40
50
60
1 2 3 4 5 6 7 8
Functioning level
Population
Eyeglasses/
Contact lenses
Cataract
Operation
Blind

12. Functioning ≡ Health

13. Health ≡ Functioning
• Health IS NOT opposite of DEATH – DISEASE
• Health is about your LIFE
» How do you life your life – How are you ?
» How do you FUNCTION?
 H e a l t h i s F U N C T I O N I N G

14. Out of Plato's Cave
• Measuring "latent"
traits
– Mobility
– Seeing
– Hearing
– Cognition
– Communication
– …

15. Health / Functioning has
Mul t i pl e DIMENSIONs
• Moving
• Seeing
• Hearing
• Eating
• ….
• ….
• Relating
• Socializing

16. World Health Assembly, 2001
 Endorse and publish ICF
 use the ICF in Member States in:
 research
 surveillance
 reporting
 Joint use with ICD
 Operational subsets:
 surveys
 clinical encounters
 Periodic revision

17. CLASSIFICATIONS& TERMINOLOGY
ICF
1. Main volume with glossary
- Full version 9999 cat.
- Short version 99 cat.
2. Clinical Descriptions
& Assessment Guidelines
3. Online access - CD Rom
4. Other versions
- Children and Youth
5. Dedicated
Assessment Tools
- Checklists
- WHO DAS 2.0

18. Principles of ICF
• Universality
– Not particular impairment groups
– Equally applicable to everyone
– Represents health as multi-dimensional
construct
• Body Functions – Impairments
– Scientific basis
• Activities
– What the individual can do / does do
• Participation
– Active performance in society
• Environment
– Interaction of person with the environment
• Identification of barriers
• Identification of facilitators

19. BODY PERSON SOCIETY
Function/ Activities Participation
Structure
(impairment) (limitation) (restriction)
BODY functions ACTIVITIES PARTICIPATION
& Structures
Key Concepts of
Functioning & Disability

23. BODY
Function/
Structure
(impairment)
PERSON
Activities
(limitation)
SOCIETY
Participation
(restriction)
ICF: MULTIDIMENSIONAL
Functioning / disability concept

24. Minority Model vs Universal Model
Everyone may have disability
Continuum
Multi-dimensional
Certain impairment groups
Categorical
Uni-dimensional

25. ICF Concepts
Impairment Activities Participation
(function/structure) (Activity Limitation) (Participation Restriction)
Health Condition
(disorder/disease)
Environmental Personal
Factors Factors

26. What should this audience NOT be told?
• Human Functioning - not merely disability
• Universal Model - not a minority model
• Integrative Model - not merely medical or social
• Interactive Model - not linear progressive
• Parity - not etiological causality
• Context - inclusive - not person alone
• Cultural applicability - not western concepts
• Operational - not theory driven alone
• Life span coverage - not adult driven

27. ICF as the Rosetta Stone
• Operational definitions
• Mapping across instruments
• Anchoring extent of difficulty
with known calibrators
• Distinguishing health states,
symptoms, functional abilities
and performance
• International comparability

28. Clinical Language
"… have been speaking prose without knowing it …"
• Everything that is not poetry
is prose
• "Good Heavens! For more
than forty years I have been
speaking prose without
knowing it."
Le Bourgeois Gentilhomme
Molière (1670) Act 2 Scene 4
• Theory
• Tools
• Practice

29. "Unless we measure
health, we cannot
manage and improve
health systems. The
ICF is the ruler with
which we will take
precise measurements
of health and disability”.
Dr Gro Harlem Brundtland
Director General Emeritus, WHO
“The ICF is the ruler…”

30. 0
5
10
15
20
25
30
35
M
a
lta
Ita
ly
G
e
rm
a
n
y
P
o
la
n
d
N
e
th
erlan
d
s
S
w
ed
e
n
S
p
ain
N
o
rw
ay
Prevalencein%/YLDs
Disability Prevalence in selected
EU countries

31. Health Information
Exchange
• Map Questions to ICF
• Map response scale to ICF Qualifiers
– seek equivalence
– Use Modern Item Response Theory to
achieve comparability between different tools

32. WHODAS 2.0
ICF based assessment instrument for measuring
health and disability
 Developed after extensive cross-cultural
and psychometric testing
 6 Domains
 Understanding the world around you
 Getting Around
 Self-Care
 Getting along with people
 Life activities (household, work)
 Participation in Society
 Advanced Scoring
 Domain and summary score
 Population norms
 No. of disability days in last month
 Available as
 Short version (12 items)
 Long version (36 items)

33. 0.8
1.07
0.44
0.72
0.74
0.81
0.23
1.32
0 0.5 1 1.5
Outpatient care
(Mexico City)
Outpatient care
(Ibadan, Nigeria)
Outpatient care of
elderly (London, UK)
Primary health care
(Seattle, USA)
WHO DAS II Comparator
WHO DAS 2.0
Responsiveness in subjects with depression
Effect size
( mean/ SD1)
LHS
LHS
SF-36 (MCS)
SF-36 (MCS)
N = 100
N = 60
N = 40
N = 73

34. ICD-10 B24 HIV disease B24 HIV disease
ICF activity limitations
performance restriction in:
Moving around (d455.44)
Washing (d510.33)
Education (d830.44)
…
Almost fully functional
moderate participation restriction in
Higher education (d830.03)

35. Separate Classification of
Disease and Disability
+ = case
Diagnosis Disability => better
formulation
of caseness

36. Operationalization of Diagnosis
ICD
A Specific phenomenology
B Signs and Symptoms
C ….
D Exclusion rules
DSM
A Specific phenomenology
B Signs and Symptoms
C DISABILITY & DISTRESS
D Exclusion rules

37. How do we
optimize
our health
services
Health Systems & Information Systems:
Analog to Digital

38. Placing WHO Classifications in HIS & IT
Population Health
• Births
• Deaths
• Diseases
• Disability
• Risk factors
e-Health Record
Systems
ICD
ICF
ICHI
Classifications
Mappings
Terminologies
Clinical
• Decision Support
• Integration of care
• Outcome
Administration
• Scheduling
• Resources
• Billing
Reporting
• Cost
• Needs
• Outcome

39. ICF Ontology: Knowledge Representation
Common sense/intuition  Disciplined definitions
"One day I read a book and whole my life changed "
Orhan Pamuk, Nobel Literature Laurate, 2006

40. Ontology
(philosophy)
• Being And Nothingness
An Essay in Phenomenological Ontology
• the Organization of Reality
• is an oxymoron  !!!

41.  Ontology (computer science)
– the explicit – operational description
of the conceptualization of a domain
• Entities
• Atributes
• Values
• An ontology defines:
– a common vocabulary
– a shared understanding/exchange:
• among software agents
• between software and People
– to reuse data - information
– to introduce standards to allow
interoperability
– among People ?
What is “NOntology” ?

42. Knowledge Representation
the triad of things, thoughts and words
(Ogden & Richards, 1923 )
APPLE
TERM

43. Conclusion
# ICFOntology
• Development of Health Information
Systems is the second most critical issue
in Health Care today
• Integration of Functioning and
Disability Information in HIS essential
– Mapping of Assessment Instruments to ICF
– Mapping between ICF and clinical
terminologies (SNOMED-CT)

44. • Placing ICF in the Health Information Systems & IT
• Real on-line data capture & analysis for:
• clients
• providers
• decision-makers
• Develop linkages to health information bases:
• Population registry
• Insurance systems
• Health services
• Develop relation-standards, tools & exchange platforms
• Demonstrate feasibility and utility
• direct consumer access
• Service provision: volume and flow management, resource allocation
• Reporting: Needs, Outcomes, Costs
ICF Vision

45. This can also help close
the information gaps with digital outreach

46. Interoperability

47. Stock Exchange
Health Information Exchange

48. Questions & Answers
ustunb@who.int
@ustunb

49. “Diagnosis” alone fails to predict:
• service needs (National Advisory Mental Health Council 1993)
• length of hospitalisation (McCrone and Phelan, 1994)
• level of care (Burns, 1991)
• outcome of hospitalization (Rabinowitz et al, 1994)
• receipt of disability benefits (Massel et al, 1990; Segal and Choi, 1991;
Basset and Regier)
• work performance (Gatchel et al, 1994; Massel et al, 1990)
• social integration (Ormel et al, 1993)

50. Dx + “Disability” can predict:
• health service utilization (Hoeper et al 1979; Regier et al, 1985;
Basset and Folstein, 1991; Von Korff et al,
1992; Ormel et al, 1993)
• Length of Hospitalization (Horn, 1990)
• Outcome after hospitalization (Rabinowitz et al, 1994)
• return to work (Hlatky et al, 1986)
• work performance (Massel et al, 1990)
• recovery of social integration (Tate, 1989)

51. Added Value of Disability Information
Predictive power
13%
8%
19%
28%
100%
100%
150%
123%
OR 1
OR 1
OR 1
OR 14
OR 4
OR 15
Functioning
Information